Using the SEIPS Framework to Reveal Hidden Factors That Can Complicate a Vaccine Documentation Process

Abstract

Health care organizations have deployed root cause analysis (RCA) method to identify trends and assess risks. RCA can be used whenever human error is suspected. An organization that appropriately takes a system approach when conducting an RCA, often discovers both active and latent errors that may be mitigated through system changes (e.g., policies and procedures). However, in many circumstances, the RCA is rushed, the process is not systematic, and only active errors are identified in a complex situation. In addition, the findings are oftentimes driven by hindsight bias, in which the true root causes are neither identified nor mitigated. A macro-ergonomics concept could be deployed to guide a systematic RCA, to further discover specific system issues that cause human errors and poor performance. This paper gives a specific example of how a macro-ergonomics concept, the Systems Engineering Initiative for Patient Safety (SEIPS) model, could be applied to systematic RCAs to frame data collection and analysis, and for identifying solutions to increase vaccine documentation rate in a pediatric primary care clinic. We found interactive multi-factorial issues that contributed to lack of proper vaccine documentation, such as an inefficient design of technology, the unit workflow that did not fit with its physical layout, inadequate task allocation, training, and interruptions. Multiple recommendations and their assessments are also discussed.